Prevalence and associations of multiple hypnotic prescriptions in a clinical sample

STUDY OBJECTIVES

We examined the prevalence of multiple hypnotic prescriptions and its association with clinical and demographic characteristics from the electronic health record (EHR) in the Mayo Clinic Biobank.

METHODS

Adult participants enrolled in the Mayo Clinic Biobank with an EHR number of ≥ 1 year were included (n = 52,940). Clinical and demographic characteristics were compared between participants who were and were not prescribed any hypnotic approved for insomnia by the US Food and Drug Administration and/or trazodone and in those prescribed a single vs multiple (≥ 2) hypnotics. A phenotype-based, phenome-wide association study (PheWAS) examining associations between hypnotic prescriptions and diagnoses across the EHR was performed adjusting for demographic and other confounders.

RESULTS

A total of 17,662 (33%) participants were prescribed at least 1 hypnotic and 5,331 (10%) received ≥ 2 hypnotics. Participants who were prescribed a hypnotic were more likely to be older, female, White, with a longer EHR, and a greater number of diagnostic codes (all P < .001). Those with multiple hypnotic prescriptions were more likely to be younger, female, with a longer EHR, and a greater number of diagnostic codes (all P < .001) compared with those prescribed a single hypnotic. The PheWAS revealed that participants with multiple hypnotic prescriptions had higher rates of mood disorders, anxiety disorders, suicidal ideation, restless legs syndrome, and chronic pain (all P < 1 e-10).

CONCLUSIONS

Receiving multiple hypnotic prescriptions is common and associated with a greater prevalence of psychiatric, chronic pain, and sleep-related movement disorders. Future studies should examine potential genetic associations with multiple hypnotic prescriptions to personalize treatments for chronic insomnia.

CITATION

Kolla BP, Mansukhani MP, Chakravorty S, Frank JA, Coombes BJ. Prevalence and associations of multiple hypnotic prescriptions in a clinical sample. J Clin Sleep Med. 2024;20(5):793-800.

Correlates to Improvement in Sleep Duration in Acute Mania and Depression

Objective: To examine sleep duration at admission and discharge and change in sleep duration during hospitalization in patients experiencing a manic episode and compare these parameters to patients hospitalized for major depressive disorder (MDD) during the same time frame. The correlation between sleep duration parameters in those with mania and MDD with length of hospital stay, after accounting for possible confounders, was also examined.

Methods: This retrospective study examined patients admitted to an acute care psychiatric unit from 2018 to 2021 with an episode of mania or MDD. Sleep duration was determined based on nursing observer report.

Results: The study included 41 patients with mania (32.9 ± 1.7 years) and 38 patients with MDD (32.7 ± 1.8 years). Mania patients had longer hospitalization and received higher antipsychotic and benzodiazepine doses, but fewer hypnotics (all P < .005). No differences were found in sleep duration at admission (P = .109) and discharge (P = .623) in the mania and MDD groups. Change in sleep duration was 1.14 ± 0.27 and 0.37 ± 0.28 hours (P = .05) in the groups, respectively. In those with mania, sleep duration at admission negatively correlated with length of stay (r = -0.033; P = .03). Sleep duration parameters were not correlated with length of stay in patients with MDD.

Conclusion: There was a trend toward greater improvement in sleep duration in inpatients with mania versus MDD. Sleep duration at admission correlated with length of hospitalization in patients with mania. Future studies should examine whether attempts to increase sleep duration can improve patient outcomes.

Prim Care Companion CNS Disord 2024;26(1):23m03620.

Author affiliations are listed at the end of this article.

Are clinical trials for insomnia recruiting real-world patients?

Recent Phase III trials of hypnotic medications that have led to Food and Drug Administration approval have severely restrictive eligibility criteria. One hundred patients referred for insomnia who received a hypnotic medication at a large tertiary referral center were identified. Data were extracted to evaluate whether these patients would be eligible to be included in any of the recent Phase III trials. Of the 100 patients identified, only 3 were eligible. Most were excluded because of a prior or concurrent trial of cognitive behavioral therapy for insomnia. If this criterion were set aside, only 12% would have been eligible to participate. The remaining top reasons for exclusion were medical comorbidities, daytime napping, and sleep apnea. These findings question the generalizability of the regulatory studies and suggest that future trials should enroll patients with less-restrictive criteria to help determine the effectiveness of these medications in real-world settings.

CITATION

Golebiowski R, Mansukhani MP, Kolla BP. Are clinical trials for insomnia recruiting real-world patients? J Clin Sleep Med. 2023;19(8):1553-1555.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Sex-specific associations between daytime sleepiness, chronic diseases and mortality in obstructive sleep apnea

Objective

Excessive daytime sleepiness (EDS) is common in obstructive sleep apnea (OSA) and has been linked to adverse outcomes, albeit inconsistently. Furthermore, whether the prognostic impact of EDS differs as a function of sex is unclear. We aimed to assess the associations between EDS and chronic diseases and mortality in men and women with OSA.

Methods

Newly-diagnosed adult OSA patients who underwent sleep evaluation at Mayo Clinic between November 2009 and April 2017 and completed the Epworth Sleepiness Scale (ESS) for assessment of perceived sleepiness (N = 14,823) were included. Multivariable-adjusted regression models were used to investigate the relationships between sleepiness, with ESS modeled as a binary (ESS > 10) and as a continuous variable, and chronic diseases and all-cause mortality.

Results

In cross-sectional analysis, ESS > 10 was independently associated with lower risk of hypertension in male OSA patients (odds ratio [OR], 95% confidence interval [CI]: 0.76, 0.69-0.83) and with higher risk of diabetes mellitus in both OSA men (OR, 1.17, 95% CI 1.05-1.31) and women (OR 1.26, 95% CI 1.10-1.45). Sex-specific curvilinear relations between ESS score and depression and cancer were noted. After a median 6.2 (4.5-8.1) years of follow-up, the hazard ratio for all-cause death in OSA women with ESS > 10 compared to those with ESS ≤ 10 was 1.24 (95% CI 1.05-1.47), after adjusting for demographics, sleep characteristics and comorbidities at baseline. In men, sleepiness was not associated with mortality.

Conclusion

The implications of EDS for morbidity and mortality risk in OSA are sex-dependent, with hypersomnolence being independently associated with greater vulnerability to premature death only in female patients. Efforts to mitigate mortality risk and restore daytime vigilance in women with OSA should be prioritized.

The Interaction Between Brain-Derived Neurotrophic Factor Levels and Alcohol Consumption, Sleep Disturbance and Sex-Hormones in Alcohol Use Disorders

AIMS

Brain-derived neurotrophic factor (BDNF) levels may be associated with alcohol use disorders (AUD) and alcohol consumption, correlate with sleep disturbance and be influenced by sex differences and sex hormones. These associations have not been examined in a single sample accounting for all these factors.

METHODS

Data from 190 participants (29.4% female) with AUD were utilized. Sleep quality, craving intensity, depression, anxiety and alcohol consumption were assessed using the Pittsburgh Sleep Quality Index (PSQI), Penn Alcohol Craving Scale (PACS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and Timeline Follow Back for 90 days(TLFB 90). Inventory of Drug Taking Situations (IDTS) assessed the tendency to drink in positive/negative emotional states. Serum BDNF (sBDNF) and plasma sex hormones (estrogen, progesterone, testosterone, FSH and SHBG) were measured. Pearson correlation analyses were used to examine the association between sBDNF and these measures in the entire sample and in men and women separately. Higher order interaction effects between these factors were evaluated for their association with sBDNF using a backward selection model.

RESULTS

No significant correlations between sBDNF levels and sex hormones, PSQI, PHQ-9, PACS, IDTS scores and alcohol consumption were found (all P-values > 0.05). sBDNF levels were negatively correlated with GAD-7 scores in men (r = -0.1841; P = 0.03). When considering all quadratic and two-way interactions among PSQI, PHQ-9, GAD-7, mean and max drinks/day, number of drinking days, heavy drinking days, and sex no higher order moderating effects of sBDNF levels were found.

CONCLUSION

Our study revealed no significant associations between sBDNF and alcohol measures, sleep, depression and sex hormones suggesting limited utility as a biomarker.

Prophylactic Use of Ramelteon for Delirium in Hospitalized Patients: A Systematic Review and Meta-Analyses

BACKGROUND

Small prospective studies, case reports, as well as some randomized placebo-controlled trials and previous meta-analyses have shown that ramelteon, a melatonin agonist, may reduce the risk of developing delirium.

OBJECTIVE

The goal of this systemic review and meta-analyses was to assess the current evidence supporting the use of ramelteon in delirium prevention by including data from larger (>100 subjects) and more recent trials since the most recent meta-analyses were published in 2019. There were no exclusions for trial size, age, ramelteon dose, length of treatment, or hospital setting.

METHODS

Medline, Embase, PsycINFO, EBM Reviews, Scopus, and Web of Science databases were queried using the search terms delirium (with subterms including prevention and control), ramelteon, Rozerem, or melatonin receptor agonists, for English-language publications until March 16, 2021. Randomized placebo-controlled trials of hospitalized subjects receiving ramelteon for delirium prevention were included. The primary outcome of interest was delirium incidence. Odds ratios of the risk of developing incident delirium and 95% confidence intervals were calculated using a random effects model.

RESULTS

A total of 177 articles were identified by the literature search. Five studies (n = 443, 53.7% male) met criteria for inclusion in the final meta-analyses. The meta-analyses of the randomized placebo-controlled trials revealed that ramelteon did not result in a reduction in the risk of incident delirium (n = 443; odds ratio = 0.49; 95% confidence interval = 0.13-1.85). A moderate degree of heterogeneity was noted among the studies (I² = 53%).

CONCLUSIONS

Current evidence suggests that ramelteon is ineffective as a prophylactic drug in reducing the incidence of delirium in hospitalized patients.

Sleep apnea and autonomic dysfunction in patients with dementia

Sleep apnea is common sleep disorder that is associated with an is an increase in risk of many health conditions, including systemic hypertension, stroke, atrial fibrillation, and heart failure. The predominant underlying pathophysiological mechanism for elevated risk of these conditions in patients with sleep apnea is thought to involve autonomic dysfunction in the form of sympathetic overactivity. Autonomic dysfunction is also associated with several neurodegenerative disorders and sleep apnea, in turn, has been shown to be associated with an increased risk of development of mild cognitive impairment and various types of dementia. Rapid eye movement sleep behavior disorder, which is also associated with an increased risk of alpha synucleiopathy-related dementia, is also linked with autonomic dysfunction. In this article we explore the relationship between sleep apnea, autonomic dysfunction, rapid eye movement sleep behavior disorder and dementia. This article describes the various autonomic dysfunction that are thought to occur in the context of sleep apnea. And illustrate the mechanisms by which sleep apnea, through its impact on autonomic dysfunction could potentially result in dementia. We also review the evidence examining the impact of treatment of sleep apnea on autonomic dysfunction and cognitive outcomes.

Assessing the quality of publicly available videos on MDMA-assisted psychotherapy for PTSD

BACKGROUND AND OBJECTIVES

Patients increasingly rely on the Internet for healthcare information. This study aimed to evaluate the quality of videos on 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for posttraumatic stress disorder (PTSD) on YouTube™.

METHODS

YouTube™ was searched for the terms "MDMA" and "PTSD." The 100 most viewed videos were analyzed using three standard quality measures: Global Quality Scores (GQS), JAMA benchmark, and DISCERN. Viewer engagement features and source of upload, video duration, inclusion of patient narrative and/or MD/DO/PhD, the mention of lack of Food and Drug Administration (FDA) approval, side effects, potential for abuse, and use in conjunction with psychotherapy were recorded.

RESULTS

The videos were of poor quality (mean GQS: 2.26 ± 0.94/5, JAMA: 1.96 ± 0.45/4, and DISCERN: 29.5 ± 8.2/80). A significant positive association was found between video quality and duration (GQS: r = .5857, p < .0001, JAMA: r = .279, p = .0409, DISCERN: r = .5783, p < .0001). Videos including an MD/DO/PhD had the highest scores (GQS: 2.87/5 [1.22], p = .006, DISCERN: 38.35/80 [13.32], p < .0003). A minority of videos were uploaded by academic institutions (1%); most were from professional organizations (29%). No correlation was found between quality and viewer engagement features-number of views, subscribers, likes/dislikes, or comments. A majority mentioned that MDMA must be used in conjunction with psychotherapy (85%) and is not FDA-approved (82%) for PTSD. Only 32% of videos mentioned risks or potential for abuse.

CONCLUSIONS

These findings highlight the need for better quality of online health material and an opportunity for involvement of healthcare professionals in the dissemination of accurate health information via content creation.

SCIENTIFIC SIGNIFICANCE

This is the first study to examine publicly available information on the use of MDMA for PTSD.

Delayed onset sleep-related stridor due to radiation for thyroid cancer

Radiation therapy is the mainstay of treatment for head and neck cancers with both acute and delayed complications. While obstructive sleep apnea is common in the few series of patients undergoing radiation therapy to the neck, the development of sleep-related stridor is exceedingly rare and has typically been reported in the acute treatment setting. We describe a 65-year-old female with 1 year of nocturnal groaning beginning 2 years after radiation therapy for thyroid carcinoma. Polysomnography revealed mild obstructive sleep apnea and sleep-related stridor responsive to nasal continuous positive airway pressure. Our case highlights the importance of screening patients with a history of head and neck radiation for sleep-related breathing complaints at each follow-up visit and consideration of both obstructive sleep apnea and stridor in these patients. Identification of sleep-disordered breathing in these patients may lead to timely treatment and improvement in quality of life.

CITATION

McCarter SJ, Mansukhani MP, Herold DL, Kolla BP. Delayed onset sleep-related stridor due to radiation for thyroid cancer. J Clin Sleep Med. 2022;18(9):2327-2329.

The Effects of Cannabinoids on Sleep

The use of cannabis products to help with sleep and various other medical conditions by the public has increased significantly in recent years. Withdrawal from cannabinoids can lead to sleep disturbance. Here, we describe a patient who developed significant insomnia leading to worsening anxiety, mood, and suicidal ideation in the setting of medical cannabis withdrawal, prompting presentation to the Emergency Department and inpatient admission. There is a limited evidence base for the use of cannabis products for sleep. We provide a comprehensive review evaluating the literature on the use of cannabis products on sleep, including an overview of cannabis and related psychoactive compounds, the current state of the law as it pertains to the prescribing and use of these substances, and potential side effects and drug interactions. We specifically discuss the impact of cannabis products on normal sleep and circadian sleep-wake rhythms, insomnia, excessive daytime sleepiness, sleep apnea, parasomnias, and restless legs syndrome. We also describe the effects of cannabis withdrawal on sleep and how this increases relapse to cannabis use. Most of the studies are observational but the few published randomized controlled trials are reviewed. Our comprehensive review of the effects of cannabis products on normal sleep and sleep disorders, relevant to primary care providers and other clinicians evaluating and treating patients who use these types of products, shows that cannabis products have minimal to no effects on sleep disorders and may have deleterious effects in some individuals. Further research examining the differential impact of the various types of cannabinoids that are currently available on each of these sleep disorders is required.

Prevalence of insomnia symptoms and associated risk factors in UK Biobank participants with hazardous alcohol use and major depression

INTRODUCTION

We aimed to examine the prevalence of insomnia symptoms (IS), sleep duration, and associated risk factors in participants with hazardous/harmful alcohol use (HAU), major depressive disorders (MDD), and HAU+MDD.

METHODS

Data from the UK Biobank (UKB) (n = 55,000) were utilized to categorize participants into those with MDD (n = 5612), HAU (n = 15,893), MDD+HAU (n = 3738), and controls (n = 29,511). We examined whether rates of IS and sleep duration differed among the groups and determined the clinical predictors of IS. Rates of IS and sleep duration were compared using regression analyses accounting for demographic (age, sex, ethnicity, Townsend deprivation index) and clinical (body mass index, neuroticism score, alcohol consumption) factors.

RESULTS

The unadjusted prevalence of IS was 26.5%, 27%, 39.5%, and 43% in control, HAU, MDD, and MDD+HAU categories respectively. Rates of IS in controls versus HAU and MDD versus MDD+HAU did not differ in unadjusted models (p = 0.45 and 0.075, respectively). Prevalence of IS differed in the four groups (p < 0.0001 for all pairwise comparisons) after adjusting for demographic confounders. After further adjustment for clinical factors, effect sizes were reduced, but pairwise comparisons remained significant. After adjusting for demographic and clinical factors, sleep duration did not differ among the groups. After accounting for diagnostic category and demographic/clinical factors, older age (OR=1.33 per 10 year increase; p < 0.0001), female sex (OR=1.39; p < 0.0001), obesity (OR=1.17 compared to normal; p < 0.0001), higher neuroticism score (OR=1.13; p < 0.0001), and alcohol consumption (OR=1.01 per serving increase; p < 0.0001) were associated with IS.

CONCLUSION

Sleep-related morbidity is the greatest in the MDD+HAU group, followed by the MDD group. Demographic and clinical characteristics explain some, but not all of the differences in the prevalence of IS in MDD±HAU. Genetic and other factors capable of influencing IS in those with MDD, HAU, and MDD+HAU merit future investigation.

Management of Restless Legs Syndrome in Pregnancy and Lactation

Restless legs syndrome (RLS) affects about 20% of all pregnant women. RLS symptoms are usually moderate to severe in intensity during pregnancy and can result in insomnia, depression, and other adverse outcomes. Although iron deficiency has been implicated as a potential etiological factor, other mechanisms can also play a role. Nonpharmacologic methods are the primary recommended form of treatment for RLS in pregnancy and lactation. Iron supplementation may be considered when the serum ferritin is low; however, several patients are unable to tolerate iron or have severe symptoms despite oral iron replacement. Here, we describe a case of severe RLS in pregnancy and illustrate the dilemmas in diagnosis and management. We review the literature on the prevalence, diagnosis, course, possible underlying pathophysiologic mechanisms and complications of RLS in pregnancy. We describe current best evidence on the efficacy, and safety of nonpharmacologic therapies, oral and intravenous iron supplementation, as well as other medication treatments for RLS in pregnancy and lactation. We highlight gaps in the literature and provide a practical guide for the clinical management of RLS in pregnancy and during breastfeeding.

Challenges in the Treatment of Restless Legs Syndrome: A Case Report

Treatment resistant restless legs syndrome (RLS) in the setting of psychiatric comorbidities can be difficult to manage. Our patient is a 69-year-old Caucasian gentleman with bipolar disorder type I, unspecified anxiety disorder, obstructive sleep apnea (OSA), and treatment-refractory RLS. At initial presentation, the patient’s prescribed medication regimen included fluoxetine 40 mg daily, gabapentin 800 mg in the morning and 3200 mg at bedtime, pramipexole 0.375 mg daily, lamotrigine 200 mg daily, trazodone 200 mg at bedtime, and temazepam 15 to 30 mg as needed for insomnia and RLS. Over the course of nearly 4 years, treatment interventions for this patient’s RLS included: cognitive behavioral therapy for insomnia, discontinuation of exacerbating medications, switching dopamine agonists, use of pregabalin and iron supplement. This report demonstrates a challenging case of RLS in the setting of psychiatric comorbidities, development of augmentation, and polypharmacy.

Frequency of sleep-disordered breathing in a referral population of Somali-Americans

STUDY OBJECTIVES

To study the frequency of obstructive sleep apnea (OSA) in individuals of Somali ancestry referred to a clinical sleep laboratory.

METHODS

This was a retrospective study using a large registry of patients who underwent diagnostic polysomnography between 17 November 2009 and 15 April 2017. Adult patients self-reporting as being of Somali origin were confirmed using the electronic medical record.

RESULTS

Somali-American patients comprised approximately 0.2% of all patients undergoing polysomnography at the Mayo Clinic Center for Sleep Medicine. The median (interquartile range) age was 52.6 (35, 64) years with 66% males and a median (interquartile range) body mass index of 31.2 (27, 34) kg/m². OSA was diagnosed in 77% of patients, with approximately 50% having moderate to severe OSA. OSA was more frequent in older patients and similar between men and women, and only age predicted an OSA diagnosis while sex and body mass index did not. All patients with diabetes mellitus type 2 (n = 7) and all but one of the hypertensive patients (n = 11) had significant OSA.

CONCLUSIONS

Less than 0.2% of all patients undergoing polysomnography at Mayo Clinic were of Somali origin. Moderate-to-severe OSA was frequent in this select sample of individuals who underwent polysomnography. Hypertension and diabetes were present in most Somali-Americans with OSA. Given the rising prevalence of diabetes and hypertension in Somali-Americans, and the likely high prevalence of undiagnosed OSA, screening Somali-Americans for sleep disorders may contribute importantly to prevention, early detection, and reduction of cardiovascular and metabolic diseases in this population.

The influence of antidepressants and actigraphy-derived sleep characteristics on pediatric multiple sleep latency testing

STUDY OBJECTIVES

Research evaluating the influence of rapid eye movement suppressing antidepressants (REMS-AD) on multiple sleep latency test (MSLT) results and the value of performing actigraphy prior to this test in children and adolescents is lacking. We examined the impact of REMS-AD and actigraphy parameters on mean sleep latency (MSL) and sleep-onset REM episodes (SOREMs) on MSLT in a pediatric clinical sample.

METHODS

This was a retrospective chart review at a quarternary referral center. We identified 164 MSLTs conducted in patients aged less than 18 years between 2014-2017. Correlations between REMS-AD, self-reported sleep duration, actigraphy parameters and each of the outcomes (MSL and SOREMs) were examined. Regression analyses accounting for clinical characteristics were performed.

RESULTS

Mean age of the sample was 11.9±4.19 years, 62% were female, 28 (17%) were on REMS-AD (48% of whom were able to discontinue these medications prior to MSLT) and mean pediatric daytime sleepiness score was 21.7±6.1. MSL was 11.27±5.77 min and mean number of SOREMs 0.55±1.04. Patients on a REMS-AD at initial assessment had fewer SOREMs compared to those not taking these medications (0.17±0.19 versus 0.62±0.09; p=0.04); no difference was noted in MSL (10.36±1.10 versus 11.47±0.50; p=0.36). Increased time in bed on actigraphy (TIBa) correlated with a longer MSL and fewer SOREMs (r=0.23; p=0.04 and r=0.316; p=0.004 respectively). Following regression analyses, use of REMS-AD continued to remain associated with fewer SOREMs; greater TIBa, but not self-reported sleep duration, was associated with a longer MSL (all p<0.05).

CONCLUSIONS

Clinicians should account for the use of REMS-AD and utilize actigraphy to determine time in bed while interpreting the results of a pediatric MSLT.

Excessive Daytime Sleepiness: A Clinical Review

Excessive daytime sleepiness (EDS) is a highly prevalent condition that is associated with significant morbidity. The causes of EDS are varied, and include inadequate sleep, sleep disordered breathing, circadian rhythm sleep-wake disorders, and central disorders of hypersomnolence (narcolepsy, idiopathic hypersomnia, and Kleine-Levin syndrome). Additionally, EDS could represent a symptom of an underlying medical or psychiatric disorder. Assessment of EDS includes a thorough sleep, medical, and psychiatric history, targeted clinical examination, and appropriate use of actigraphy to measure sleep duration and sleep-wake patterns, polysomnography to assess for associated conditions such as sleep-related breathing disorders or other factors that might disrupt nighttime sleep, multiple sleep latency testing to ascertain objective sleepiness and diagnose central disorders of hypersomnolence, and measurement of cerebrospinal fluid hypocretin-1 concentration. Treatment of EDS secondary to central disorders of hypersomnolence is primarily pharmacologic with wakefulness-promoting agents such as modafinil, stimulants such as methylphenidate and amphetamines, and newer agents specifically designed to improve wakefulness; behavioral interventions can provide a useful adjunct to pharmacologic treatment. When excessive sleepiness is secondary to other conditions, the treatment should focus on targeting the primary disorder. This review discusses current epidemiology, provides guidance on clinical assessments and testing, and discusses the latest treatment options. For this review, we collated the latest evidence using the search terms excessive sleepiness, hypersomnia, hypersomnolence, treatment from PubMed and MEDLINE and the latest practice parameters from the American Academy of Sleep Medicine.

The Association of Sleep Apnea and Cardiorespiratory Fitness With Long-Term Major Cardiovascular Events

OBJECTIVE

To determine the risk of long-term major adverse cardiovascular events (MACE) when sleep-disordered breathing (SDB) and decreased cardiorespiratory fitness (CRF) co-occur.

METHODS

We included consecutive patients who underwent symptom-limited cardiopulmonary exercise tests between January 1, 2005, and January 1, 2010, followed by first-time diagnostic polysomnography within 6 months. Patients were stratified based on the presence of moderate-to-severe SDB (apnea/hypopnea index ≥15 per hour) and decreased CRF defined as <70% predicted peak oxygen consumption (VO₂). Long-term MACE was a composite outcome of myocardial infarction (MI), coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), stroke or transient ischemic attack (TIA), and death, assessed until May 21, 2018. Cox-proportional hazard models were adjusted for factors known to influence CRF and MACE.

RESULTS

Of 498 included patients (60±13 years, 28.1% female), 175 (35%) had MACE (MI=17, PCI=14, CABG=13, stroke=20, TIA=12, deaths=99) at a median follow-up of 8.7 years (interquartile range=6.5 to 10.3 years). After adjusting for age, sex, beta blockers, systemic hypertension, diabetes mellitus, coronary artery disease, cardiac arrhythmia, chronic obstructive pulmonary disease, smoking, and use of positive airway pressure (PAP), decreased CRF alone (hazard ratio [HR]=1.91, 95% confidence interval [CI], 1.15 to 3.18; P=.01), but not SDB alone (HR=1.26, 95% CI, 0.75 to 2.13, P=.39) was associated with increased risk of MACE. Those with SDB and decreased CRF had greater risk of MACE compared with patients with decreased CRF alone (HR=1.85; 95% CI, 1.21 to 2.84; P<.005) after accounting for these confounders. The risk of MACE was attenuated in those with reduced CRF alone after additionally adjusting for adequate adherence to PAP (HR=1.59; 95% CI, 0.77 to 3.31; P=.21).

CONCLUSION

The incidence of MACE, especially mortality, was high in this sample. Moderate-to-severe SDB with concurrent decreased CRF was associated with higher risk of MACE than decreased CRF alone. These results highlight the importance of possibly including CRF in the risk assessment of patients with SDB and, conversely, that of screening for SDB in patients with low peak VO₂.

Increased Patient Safety-Related Incidents Following the Transition into Daylight Savings Time

BACKGROUND

"Spring forward," the start of daylight savings time (DST), reduces sleep opportunity by an hour. Insufficient sleep in healthcare workers resulting from the spring forward time change could potentially result in an increase in medical errors.

OBJECTIVE

We examined the change in reported patient safety-related incidents (SRIs), in the week following the transition into and out of DST over a period of 8 years.

DESIGN

Observational study SETTING: A US-based large healthcare organization with sites across multiple states MEASUREMENTS: Voluntarily reported SRIs that occurred 7 days prior to and following the spring and fall time changes for years 2010-2017 were ascertained. SRIs likely resulting from human error were identified separately. The changes in the number of SRIs (either all SRIs or SRIs restricted to those likely resulting from human error) from the week before and after the time change (either spring or fall) were modeled using a negative binomial mixed model with a random effect to correct for non-independent observations in consecutive weeks.

RESULTS

Over the 8-year period, we observed 4.2% (95% CI: - 1.1 to 9.7%; p = 0.12) and 8.8% (95% CI: - 2.5 to 21.5%; p = 0.13) increases in overall SRIs in the 7 days following DST when compared with 7 days prior for spring and fall, respectively. By restricting to SRIs likely resulting from human errors, we observed 18.7% (95% CI: 5.6 to 33.6%; p = 0.004) and 4.9% (95% CI: - 1.3 to 11.5%; p = 0.12) increases for spring and fall, respectively.

CONCLUSION

Policy makers and healthcare organizations should evaluate delayed start of shifts or other contingency measures to mitigate the increased risk of SRIs during transition to DST in spring.

Pharmacological Management of Insomnia

Insomnia is a highly prevalent condition associated with significant morbidity, reduction in quality of life, and increase in healthcare costs, and is a risk factor for multiple physical and mental disorders. The primary treatment modality is cognitive behavioral therapy for insomnia (CBT-I) but this is associated with difficulties with access and higher cost as well as poor response in some patients. Therefore, pharmacotherapy for insomnia is common and hypnotic agents are among the most frequently prescribed medications in the United States. Older medications for insomnia are limited by their side effect burden and narrow therapeutic window. Newer hypnotics, on the other hand, have been shown to have a better safety profile and longer term efficacy. While some studies have shown that long-term hypnotic use is associated with adverse outcomes, the current evidence is equivocal. The decision to treat chronic insomnia disorder with long-term hypnotics should be individualized and balance the potential risks of continuing hypnotic medication use with the risks of untreated persistent insomnia and associated functional limitations. This clinical review discusses the currently available medication options to treat insomnia, their mechanisms of action, dosing, and side effect profiles. This review also provides guidance on long-term management of hypnotics and the use of these medications in the elderly, those with medical comorbidities, and other special populations.

Medication-Assisted Treatment for Opioid Use Disorder in a Rural Family Medicine Practice

Opioid use disorder (OUD) is a cause of significant morbidity and mortality in the United States. Although efforts are being made to limit access to prescription opioids, the use of heroin and synthetic opioids as well as death due to opioid overdose has increased. Medication-assisted treatment (MAT) is the pairing of psychosocial intervention with a Food and Drug Administration (FDA)-approved medication (methadone, buprenorphine plus naltrexone) to treat OUD. MAT has resulted in reductions in overdose deaths, criminal activity, and infectious disease transmission. Access to MAT in rural areas is limited by shortages of addiction medicine-trained providers, lack of access to comprehensive addiction programs, transportation, and cost-related issues. Rural physicians express concern about lack of mentorship and drug diversion as reasons to avoid MAT. The prescribing of MAT with buprenorphine requires a Drug Enforcement Agency (DEA) waiver that can easily be obtained by Family Medicine providers. MAT can be incorporated into the outpatient practice, where patient follow-up rates and number needed to treat to effect change are similar to that of other chronic medical conditions. We describe a case of opioid overdose and a suggested protocol for the induction of MAT with buprenorphine/naloxone (Suboxone) for OUD in a rural family medicine outpatient practice. Treatment access is facilitated by utilizing the protocol, allowing office staff work to the extent allowed by their licensure, promoting teamwork and minimizing physician time commitment. We conclude that improved access to MAT can be accomplished in a rural family medicine outpatient clinic by staff that support and mentor one another through use of a MAT protocol.

0738 Advance Taper of Antidepressants Prior to Multiple Sleep Latency Testing Increases the Number of Sleep-Onset Rapid Eye Movement Periods and Reduces Mean Sleep Latency

Introduction

Patients presenting with excessive sleepiness are frequently on antidepressant medication(s). While practice parameters recommend discontinuation of antidepressants prior to multiple sleep latency testing (MSLT), data examining the impact of tapering these medications on MSLT results are limited.

Methods

Adult patients who underwent MSLT at Mayo Clinic Rochester, Minnesota, between 2014-2018 were included. Clinical and demographic characteristics, medications, including use of rapid eye movement suppressing antidepressants (REMS-AD) at assessment and during testing, actigraphy and polysomnography data were manually abstracted. The difference in number of sleep-onset rapid eye movement periods (SOREMS), proportion with ≥2 SOREMS and mean sleep latency (MSL) in patients who were on REMS-AD and discontinued prior to testing versus those who remained on REMS-AD were examined. At our center, all antidepressants are discontinued 2 weeks prior to MSLT wherever feasible; fluoxetine is stopped 4 weeks prior. Regression analyses accounting for demographic, clinical and other medication-related confounders were performed.

Results

A total of 502 patients (age=38.18±15.90 years; 67% female) underwent MSLT; 178 (35%) were on REMS-AD at the time of assessment. REMS-AD were discontinued prior to testing in 121/178 (70%) patients. Patients tapered off REMS-AD were more likely to have ≥2 SOREMS (OR-12.20; 95%CI=1.60-92.94) compared to patients who remained on REMS-AD at the time of the MSLT. They also had shorter MSL (8.77±0.46 vs 10.21±0.28; p&gt;0.009) and higher odds of having ≥2 SOREMS (OR=2.22; 95%CI=1.23-3.98) compared to patients not on REMS-AD at initial assessment. These differences persisted after regression analyses accounting for confounders.

Conclusion

Patients who taper off REMS-AD prior to MSLT are more likely to demonstrate ≥2SOREMs and have a shorter MSL. Pending further prospective investigations, clinicians should preferably withdraw REMs-AD before an MSLT. If this is not done, the test interpretation should include a statement regarding the potential effect of the drugs on the results.

Support

None

0719 The Association of Sleep Apnea and Cardiorespiratory Fitness with Long-Term Major Cardiovascular Events

Introduction

Sleep disordered breathing (SDB) is associated with adverse cardiovascular outcomes and decreased cardiorespiratory fitness (CRF). The risk of long-term major adverse cardiovascular events (MACE) when SDB and decreased CRF co-occur has not been determined.

Methods

We included consecutive patients that underwent a symptom-limited cardiopulmonary exercise test followed by first-time diagnostic polysomnography within 6 months. Patients were stratified based on the presence of moderate-severe SDB (apnea/hypopnea index ≥15/hour) and decreased CRF defined as &lt;70% predicted peak oxygen consumption (VO2). MACE was a composite outcome of myocardial infarction (MI), coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), stroke/transient ischemic attack (TIA) and death. Cox-proportional hazard models adjusting for factors known to influence CRF and MACE were constructed.

Results

Of 498 included patients (60±13 years, 28.1% female), 175 (35%) had MACE (MI=17, PCI=14, CABG=13, stroke=20, TIA=12, deaths=99) at a median follow-up of 8.7 years (interquartile range=6.5-10.3 years). After adjusting for age, sex, beta-blockers, systemic hypertension, diabetes mellitus, coronary artery disease, cardiac arrhythmia, chronic obstructive pulmonary disease, smoking and positive airway pressure (PAP) usage, decreased CRF alone (HR=1.91, 95%CI=1.15-3.18, p=0.012), but not SDB alone (HR=1.26, 95%CI=0.75-2.13, p=0.389) was associated with increased risk of MACE. Those with SDB and decreased CRF had increased risk of MACE compared to patients with decreased CRF alone (HR=1.85, 95%CI=1.21-2.84, p&lt;0.005) after accounting for these confounders; the risk was attenuated after additionally adjusting for adequate adherence to PAP (HR=1.85, 95%CI=0.99-3.05, p=0.05).

Conclusion

The incidence of MACE, including mortality, was high in this sample. Moderate-severe SDB with concurrent decreased CRF was associated with higher risk of MACE than decreased CRF alone. These results highlight the importance of including CRF in the risk assessment of patients with SDB, and conversely, that of screening for SDB in patients with low peak VO2.

Support

None.

0173 Spring Forward, Fall Back: Increased Patient Safety-Related Adverse Events Following the Spring Time Change

Introduction

“Spring forward,” the start of daylight savings time (DST) reduces sleep opportunity by an hour. The resulting sleep deprivation in healthcare workers can increase the potential for medical errors. We examined the change in patient safety-related adverse events (AEs) following the time change in both spring and fall.

Methods

Self-reported AEs that occurred 7 days prior to and following the spring and fall time changes for years 2010–2017 in a large healthcare organization were ascertained. AEs likely resulting from human errors were identified. The change in the number of AEs (all AEs or restricted to those resulting from human error) following the spring and fall time change were modeled using negative binomial mixed models using a random effect to correct for non-independent observations in consecutive.

Results

Over the 8 year period, there were more AEs (all and human) in the 7 days following the change in time both in spring (All: 2812 V. 2699; Human: 1902 V. 1625) and fall (All: 3207 V. 3007; Human: 2189 V. 2087). However, the only statistically significant increase was for the estimated 18% increase in human errors following time change in spring (95% CI: 6% to 34%; p = 0.004). The 18% AE increase in spring was also significantly greater than the 5% increase in AE in fall (p = 0.018).

Conclusion

There is a significant increase in human error related AEs following the “spring forward” clock change which can jeopardize patient safety. Based on safety considerations, DST might best be eliminated; alternatively, policy makers and healthcare organizations should evaluate measures to mitigate the increased risk during this period.

Support

NA

The Impact of Varenicline on Alcohol Consumption in Subjects With Alcohol Use Disorders: Systematic Review and Meta-Analyses

OBJECTIVE

Varenicline has been shown to be safe and effective in improving abstinence in smokers. However, results from randomized, placebo-controlled trials using varenicline for alcohol use disorders (AUDs) are inconsistent. The present systematic review and meta-analyses aimed to ascertain whether varenicline improves drinking-related outcomes in subjects with AUDs.

DATA SOURCES

Ovid, Embase, and Scopus databases were queried using the search terms varenicline, alcoholism, alcohol-related disorders, and drinking behavior for English-language publications until August 29, 2019, of randomized, placebo-controlled trials in humans.

STUDY SELECTION

A total of 197 articles were identified by the literature search. Studies of subjects with heavy drinking or alcohol dependence/AUD that reported alcohol use-related outcomes were examined.

DATA EXTRACTION

Weighted mean difference (WMD), standardized mean difference (SMD), and 95% CIs were calculated. The primary outcome of interest was percentage of heavy drinking days. Secondary outcomes included the number of drinks per drinking day, percentage of days abstinent, and change in alcohol craving.

RESULTS

Ten studies (n = 731, 66.6% male, 55.1% smokers) were included in the systematic review. In meta-analyses, no significant differences in percentage of heavy drinking days (n = 597; WMD = -1.09; 95% CI, -4.86 to 2.69; I² = 22%), number of drinks per drinking day (n = 570; WMD = -0.71; 95% CI, -1.44 to 0.03; I² = 0%), or percentage of days abstinent (n = 439; WMD = 3.89; 95% CI, -1.25 to 9.02; I² = 0%) were noted with varenicline use. Overall risk of bias was low. A statistically significant decrease in craving was observed (n = 436; SMD = -0.63; 95% CI, -1.18 to -0.08; I² = 84%).

CONCLUSIONS

In the present systematic review and meta-analyses, varenicline was shown to reduce alcohol craving but not improve drinking-related outcomes in subjects with AUDs.

Sleep disturbances in early alcohol recovery: Prevalence and associations with clinical characteristics and severity of alcohol consumption

AIMS

We aimed to assess the prevalence of sleep disturbance in early alcohol recovery and its association with psychiatric comorbidity, cravings, propensity and severity of alcohol consumption.

DESIGN

The sample consisted of 18-80 year old patients (n = 303) receiving treatment for alcohol dependence. Sleep disturbance was measured using the Pittsburgh Sleep Quality Index (PSQI). Additional measures included PHQ-9, GAD-7 and Penn alcohol cravings scale (PACS), Inventory of Drug Taking Situations (IDTS) and alcohol consumption was measured utilizing the Time Line Follow Back (TLFB).Bivariate analyses evaluated the association between PSQI total score and other clinical characteristics. A multivariable model was computed for sleep disturbance with predictors entered into the model using automated stepwise selection.

FINDINGS

The sample was majority male (66%), White (93%) with a mean age of 42.2 ± 11.6 years. Baseline PSQI score was 10.2 ± 4.13 and most subjects (88%) reported sleep disturbance at baseline. Baseline sleep disturbance was associated with depressive symptoms (p < .0001), anxiety symptoms (p < .0001), craving (p < .0001), propensity to drink when experiencing unpleasant emotions (p < .0001), physical discomfort (p < .0001), loss of personal control (p = 0.03), conflict (p = 0.002), number of drinks consumed (p = 0.004), drinking days (p = 0.004) and hazardous drinking days (p = 0.03) in bivariate analyses. However, in the multivariable model, only PHQ-9 total score and IDTS physical discomfort subscale were associated with sleep disturbance.

CONCLUSION

Sleep disruption is common in early alcohol recovery. Future studies should examine the prognostic and clinical implications of its association with current depressive symptoms and a propensity to drink while experiencing physical discomfort.

Frequency and outcomes of primary central sleep apnea in a population-based study

BACKGROUND

Primary central sleep apnea (PCSA) is believed to be rare and data regarding its prevalence and long-term outcomes are sparse. We used the Rochester Epidemiology Project (REP) resources to identify all Olmsted County, Minnesota, residents with an incident diagnosis of PCSA and their clinical outcomes.

METHODS

We searched the REP database for all residents with polysomnography (PSG)-confirmed diagnoses of central sleep apnea (CSA) between 2007 and 2015. From these, we reviewed the PSGs and medical records to find those who had PCSA based upon accepted diagnostic criteria. Data based on detailed review of the medical records, including all clinical notes and tests were recorded for analysis.

RESULTS

Of 650 patients identified with CSA, 25 (3.8%; 23 male) had PCSA, which was severe in most patients (n = 16, 64%). Of those, 23 (92%) patients were prescribed and 18/23 (78.2%) adherent to positive airway pressure therapy. Median duration of follow-up was 4.4 years (IQR:4.2). Four (16%) patients were subsequently diagnosed with cardiac arrhythmias, one (4%) with unstable angina, two (8%) with heart failure, five (20%) with mild cognitive impairment (MCI)/dementia and two (8%) with depression. Six (25%) patients died (median time to death = 5 years; IQR:4.8), three of whom had Lewy body dementia.

CONCLUSIONS

In this population-based study, PCSA was rare and when present, was severe in a majority of patients. The mortality rate was high. Most frequently observed disorders during follow-up were mild cognitive impairment (MCI)/dementia followed by cardiac arrhythmias; it is possible that these entities were present and not recognized prior to the diagnosis of PCSA.

Excessive sleepiness and associated symptoms in the U.S. adult population: prevalence, correlates, and comorbidity

OBJECTIVE

This study examined the prevalence, sociodemographic features, patterns of comorbidity, and impact on functional impairment of excessive sleepiness (Ex.S) and associated symptoms in a nationally representative sample of adults using the National Comorbidity Survey Replication (NCS-R) dataset.

METHODS

Participants ≥18 years (n = 5,962) were queried about their sleep using the Composite International Diagnostic Interview (CIDI). Specifically, respondents were questioned about feeling sleepy during the day and falling asleep in permissive situations, feelings of insufficient sleep despite adequate time in bed, and/or difficulty waking up. Those endorsing daytime sleepiness and at least one additional symptom were considered to have Ex.S plus associated symptoms. Associations between Ex.S plus associated symptoms and sociodemographics, Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) mental disorders, chronic physical conditions, and functional impairment were examined.

RESULTS

The prevalence of Ex.S plus associated symptoms in U.S. adults was 23.34% (standard error [SE] = 0.88) and significantly co-occurred with insomnia-related symptoms after adjusting for confounders (Odds ratio [OR] = 5.65; 95% confidence interval [CI] = 4.55-7.02). The presence of Ex.S and associated symptoms was more common in women, particularly younger women, those with lower family income, and the unemployed (all P<.001). After controlling for demographic characteristics and other confounders, Ex.S plus associated symptoms was associated with having a DSM-IV mental disorder (OR = 4.25; 95% CI = 3.53-5.10), a chronic physical condition (OR = 2.57; 95% CI = 1.94-3.42) and greater disability (P<.001).

CONCLUSION

Ex. S with associated symptoms was common, frequently co-occurred with other mental and physical conditions, and was associated with substantial disability. Dissipation of some associations after controlling for insomnia-related symptoms indicated that physical-mental comorbidity and disability were greater among individuals with more pervasive sleep disturbances.

The Effect of Positive Airway Pressure Treatment of Obstructive and Central Sleep Apnea on the Recurrence of Atrial Fibrillation/Flutter Postintervention

STUDY OBJECTIVES

A strong association between sleep-disordered breathing (SDB) and atrial fibrillation and/or atrial flutter (AF) has consistently been observed in epidemiologic and interventional studies. The effect of positive airway pressure (PAP) on AF recurrence is inconclusive. This study sought to evaluate the effectiveness of PAP therapy for SDB on AF recurrence.

METHODS

This was a single-center, retrospective study conducted at a tertiary referral center. All adult patients who had SDB on polysomnography and underwent AF intervention (ablation or cardioversion) following polysomnography from January 1992-December 2014 were analyzed. Primary outcome was time to first-documented recurrence of AF after AF intervention by Kaplan-Meier estimates.

RESULTS

Among 30,188 patients with obstructive and central SDB, 429 had this diagnosis before AF intervention; 269 were "PAP-adherent users," the remaining 160 were "PAP-nonusers." Patients in both groups had similar age, sex, body mass index (BMI), ejection fraction, left atrial volume index (LAVI), antiarrhythmic medications, diabetes mellitus, systemic hypertension, and heart failure diagnoses. Time to recurrence of AF postintervention was no different in PAP-adherent users and nonusers (4.8 and 4.1 months respectively, P = .7). Cardioversion (compared to catheter ablation) was the strongest independent predictor of recurrent AF (hazard ratio [HR] 2.02, 95% confidence interval [CI] 1.39-2.94, P < .001). BMI and LAVI were also significant predictors of recurrence in adjusted analyses (HR 1.01, 95% CI 1.003-1.023, P = .10 and HR 1.01, 95% CI 1.001-1.019, P = .024 respectively).

CONCLUSIONS

Our study found no effect of PAP treatment of SDB on time to recurrence of AF post-AF intervention. Increased risk of recurrent AF was associated with high BMI and LAVI. These findings may affect the clinical management of AF.

Neurological Sleep Disorders and Blood Pressure: Current Evidence

Hypertension is a major determinant of cardiovascular morbidity and mortality and is highly prevalent in the general population. While the relationship between sleep apnea and increased blood pressure has been well documented, less recognized is emerging evidence linking sleep-related movement disorders such as restless legs syndrome/periodic limb movements of sleep and sleep-related bruxism with blood pressure (BP) dysregulation and hypertension. There is also recent literature linking narcolepsy-cataplexy with elevated BP and altered pressor responses, and there are data suggesting abnormal BP control in rapid eye movement sleep behavior disorder. It is thought that neural circulatory mechanisms, sympathetic activation in particular, comprise the predominant mediator underlying elevated BP in these neurological sleep disorders. There is very limited evidence that treating these sleep disorders may be beneficial in lowering BP primarily because this question has received very little attention. In this review, we discuss the potential pathophysiologic mechanisms underlying elevated BP in restless legs syndrome/periodic limb movements of sleep, sleep-related bruxism, narcolepsy-cataplexy, and rapid eye movement sleep behavior disorder. We also examine the relationship between these sleep disorders and elevated BP and the impact of treatment of these conditions on BP control. Last, we discuss gaps in the literature evaluating the associations between these sleep disorders and elevated BP and identify areas for further research.

Hypertension and Cognitive Decline: Implications of Obstructive Sleep Apnea

Hypertension and dementia are highly prevalent in the general population. Hypertension has been shown to be a risk factor for Alzheimer's dementia and vascular dementia. Sleep apnea, another common disorder, is strongly associated with hypertension and recent evidence suggests that it may also be linked with cognitive decline and dementia. It is possible that sleep apnea is the final common pathway linking hypertension to the development of dementia. This hypothesis merits further exploration as sleep apnea is readily treatable and such therapy could foreseeably delay or prevent the onset of dementia. At present, there is a paucity of therapeutic modalities that can prevent or arrest cognitive decline. In this review, we describe the associations between hypertension, dementia and sleep apnea, the pathophysiologic mechanisms underlying these associations, and the literature examining the impact of treatment of hypertension and sleep apnea on cognition. Potential areas of future investigation that may help advance our understanding of the magnitude and direction of the interaction between these conditions and the effects of treatment of high blood pressure and sleep apnea on cognition are highlighted.

Prevalence and Correlates of Hypersomnolence Symptoms in US Teens

OBJECTIVE

Recent attention to pervasive sleep deficits in US adolescents has focused on sleep patterns and insomnia, but there are limited data on the prevalence and correlates of hypersomnolence symptoms.

METHOD

The sample included 6,483 adolescents 13 to 18 years of age who were interviewed directly and had parent reports in the National Comorbidity Survey Replication Adolescent Supplement (NCS-A), a nationally representative sample of US youth. Information on sleep patterns/symptoms that were collected in the interview was used to determine the population prevalence of DSM-5 criterion A-defined hypersomnolence and component symptoms. Logistic regression analyses were used to examine associations between sleepiness and sub-symptoms of hypersomnolence with weekday/weekend bedtime, sleep duration, mental disorders, and psychotropic medication use.

RESULTS

Of the sample, 41.5% reported feeling sleepy during the daytime and 11.7% met criteria for hypersomnolence. The prevalence of hypersomnolence varied depending on age (p < .001) and was more common in adolescent girls (odds ratio [OR] 1.40, 95% CI 1.09-1.78). Excessive sleepiness and hypersomnolence symptoms were associated with shorter sleep duration and delayed bedtimes on weekdays and weekends Hypersomnolence was significantly associated with insomnia (OR 2.45, 95% CI 1.87-3.21) and mental disorders (OR 1.99, 95% CI 1.42-2.77). After accounting for insomnia, hypersomnolence was no longer associated with use of psychotropic medication (OR 1.61, 95% CI 0.97-2.66).

CONCLUSION

Of adolescents with adequate sleep duration, 11.7% still reported symptoms of hypersomnolence. The strong association between hypersomnolence and insomnia suggests that sleep disorders in adolescents can fluctuate between over- and under-sleeping. Potential mechanisms underpinning the strong associations between sleep disturbances and mental disorders should be further pursued and could provide insight into prevention efforts.

Effect of Varying Definitions of Hypopnea on the Diagnosis and Clinical Outcomes of Sleep-Disordered Breathing: A Systematic Review and Meta-Analysis

STUDY OBJECTIVES

Various criteria have been used for scoring hypopneas, leading to difficulties when comparing results in clinical and research settings. We conducted a systematic review and meta-analysis to assess the effect of different hypopnea definitions on the diagnosis, severity, and clinical implications of sleep-disordered breathing (SDB).

METHODS

Ovid MEDLINE, Embase, and Scopus databases were queried for English-language publications from inception through March 7, 2017. Studies that directly compared various hypopnea definitions were eligible. The hierarchical summary receiver operating characteristic model was used to jointly estimate diagnostic performance for comparisons between criteria.

RESULTS

The initial search yielded 2,828 abstracts; 28 met inclusion criteria. After reviewing reference lists and expert review, five additional articles were identified. Most of the studies were cross-sectional or retrospective in nature. Eleven studies compared 2007 recommended criteria with 2012 criteria; 6 of these (evaluating 6,628 patients) were suitable for inclusion in the meta-analysis. Using the 2012 definition (≥ 3% desaturation or arousal) as the reference standard, the 2007 definition (≥ 4% desaturation) showed a sensitivity of 82.7% (95% confidence interval 0.72-0.90) and specificity of 93.2% (95% confidence interval 0.82-0.98). Although 2007 criteria were found to be associated with prevalent cardiovascular (CV) disease and increased risk of CV death, the 2012 criteria appeared to correspond better with intermediate CV risk markers based on two abstracts.

CONCLUSIONS

As expected, 2012 hypopnea scoring criteria resulted in a greater prevalence and severity of SDB. Data regarding the effect of varying hypopnea definitions on clinical outcomes, quality of life, health care costs, and mortality rates are limited.

COMMENTARY

A commentary on this article appears in this issue on page 683.

Effects of Adaptive Servoventilation Therapy for Central Sleep Apnea on Health Care Utilization and Mortality: A Population-Based Study

STUDY OBJECTIVES

Adaptive servoventilation (ASV) is the suggested treatment for many forms of central sleep apnea (CSA). We aimed to evaluate the impact of treating CSA with ASV on health care utilization.

METHODS

In this population-based study using the Rochester Epidemiology Project database, we identified patients over a 9-year period who were diagnosed with CSA (n = 1,237), commenced ASV therapy, and had ≥ 1 month of clinical data before and after ASV initiation. The rates of hospitalizations, emergency department visits (EDV), outpatient visits (OPV) and medications prescribed per year (mean ± standard deviation) in the 2 years pre-ASV and post-ASV initiation were compared.

RESULTS

We found 309 patients (68.0 ± 14.6 years, 80.3% male, apnea-hypopnea index 41.6 ± 26.5 events/h, 78% with cardiovascular comorbidities, 34% with heart failure) who met inclusion criteria; 65% used ASV ≥ 4 h/night on ≥ 70% nights in their first month. The overall 2-year mortality rate was 9.4% and CSA secondary to cardiac cause was a significant risk factor for mortality (hazard ratio 1.81, 95% CI 1.09-3.01, P = .02). Comparing pre-ASV and post-ASV initiation, there was no change in the rate of hospitalization (0.72 ± 1.63 versus 0.79 ± 1.44, P = .46), EDV (1.19 ± 2.18 versus 1.26 ± 2.08, P = .54), OPV (31.59 ± 112.42 versus 13.60 ± 17.36, P = .22), or number of prescribed medications (6.68 ± 2.0 versus 5.31 ± 5.86, P = .06). No differences in these outcomes emerged after accounting for adherence to ASV, CSA subtype and comorbidities via multiple regression analysis (all P > .05).

CONCLUSIONS

Our cohort of patients with CSA was quite ill and the use of ASV was not associated with a change in health care utilization.